Debra: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Debra James.

Rand: And I’m Rand Gardner. Coming up: This week our News and Numbers is on the chronically uninsured.

Debra: New research about medical errors and physician trainees.

Rand: And our Navigating the Health Care segment is about how to ask tough questions of your doctor. More after this.

[Begin PSA: Play It Safe, Don’t Play Around with Medicine]

Woman: Hmm, was that three pills four times a day or four pills three times a day? Do I need to wake at 2 a.m. to take one? If I missed taking the last dose should I take two doses now? Is it okay to take my vitamins with the pills? You know, I’m feeling better. Maybe I don’t need these pills anymore at all.

Narrator: Play it safe, don’t play around with medicine. If you have questions talk with your doctor or pharmacist.

[End PSA]

(music)

Debra: Now for the numbers: More than 17 million Americans nearly one in every 15 people under age 65 have gone at least four consecutive years with no health insurance to help pay their medical bills. The data from AHRQ’s 2005 Medical Expenditure Panel Survey say that middle-income people and people ages 25 to 29 were most likely to be uninsured from 2002 through 2005. By contrast, only 2 percent of children and adolescents under 18, regardless of race or ethnicity, were continuously uninsured during the period. The survey also found racial disparities in insurance coverage. In 2005, Hispanics comprised 40 percent of all Americans who had been uninsured since 2002, and also were the most likely of any racial or ethnic group to be uninsured continuously during that time.

Rand: Physicians in training are vulnerable to making medical errors that can create a serious risk to patient safety. A new AHRQ-funded study found that breakdowns in teamwork contributed to 70 percent of medical errors by medical trainees, which include medical residents, fellows and interns. Dr. Hardeep Singh, of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, led the study.

Dr. Singh: We studied malpractice claims that involved medical errors by trainees and found several types of teamwork issues to be problematic. For one, we found that breakdowns in information transfer between people occurred in very complex chains of communication. They not only occurred between two trainees but also when trainees interacted with other members of the health care team, for example, their supervising physician, nurses, pharmacy personnel and lab personnel. And sometimes, they actually involved more than 2 people.

Rand: Dr. Singh, you also found that other breakdowns were caused by a lack of supervision. Could you explain that?

Dr. Singh: Sure. In over half of the medical error cases we reviewed, we found a lack of supervision by a more experienced physician. So, for instance, this could be an attending physician’s failure to oversee the work of a resident --which actually made up the majority of cases-- or a senior resident’s failure to supervise a more junior trainee. In other cases we found teamwork problems to result from other types of communication failures, or simply from a lack of clarity about whose responsibility it was. Again, the vast majority of injuries in our study were either very serious or resulted in death. So these teamwork problems can seem rather simple on the surface but can turn out to be major players in causing poor outcomes.

Rand: And other breakdowns were caused by poor judgment or lack of technical competence or knowledge by the trainees.

Dr. Singh: Yes, errors in judgment occurred in nearly three quarters of the cases we studied. Interestingly, when we studied the lack of technical competence cases to determine the task involved, which is the task that they were doing when the error occurred, we actually found that over half of the time the trainees were either making a diagnosis or monitoring the patient or situation when the error occurred.

Rand: Now, you also found that despite a growing awareness of the relationship between poor teamwork and preventable medical errors, few graduate medical education programs pay enough attention to teamwork-based training and communication skills. How will your study help?

Dr. Singh: Effective teamwork and communication are critical for improving patient safety and our study findings reiterate that in the context of graduate medical education. One of our study investigators is conducting a trial to help understand whether and how teamwork can be improved in medicine and we actually hope that our work will inspire several similar studies in trainees in the future. Many of these teamwork-related errors are preventable and we have tried to highlight some areas of improvement for graduate medical education in our paper. If there’s one key message and if there’s one thing that the training programs can do right now to improve medical errors by trainees, is to adopt proven strategies that improve teamwork and communication.

Rand: Dr. Singh, thank you for joining us.

Dr. Singh: Thank you.

Rand: Dr. Singh led a study about medical errors caused by physicians in training. The full study is published in the October 22 issue of "Archives of Internal Medicine."

Debra: Up next, Navigating the Health Care System with Dr. Carolyn Clancy.

(music)

Debra: We all know how important it is to communicate well with our doctors, but sometimes it can be difficult to tell our doctors what we want. Our segment today about Navigating the Health Care System is about how to ask your doctor tough questions. Welcome, Dr. Clancy.

Dr. Clancy: It’s good to be here.

Debra: We’re talking about tough questions. Let’s start with asking for a second opinion. Is my doctor going to think that I don’t trust her judgment?

Dr. Clancy: In general, you should never be afraid to get a second opinion. By getting a second opinion, you get to hear someone else’s take on this and you get a much better sense of all of the options that are available to you. A good doctor will understand the value of second opinions and will actually welcome them. However, if a doctor does object or acts extremely sensitive when you ask about a second opinion, you should consider that a red flag. It may be an indication that you need to consider getting a different physician, not just another opinion.

Debra: When should someone consider getting a second opinion?

Dr. Clancy: There are many situations when a second opinion can be very helpful. If you have a serious illness and, in particular, if you have a new diagnosis; if you’re not comfortable with the treatment that your doctor has prescribed, for example. In the case of a new diagnosis, a second opinion can actually be reassuring to you and your doctor that nothing’s been overlooked, that a fresh set of eyes has reached the same conclusion, that this is, indeed, the diagnosis at hand. Second opinions can also give you an alternative perspective on your treatment options.

Debra: What happens if a person isn’t happy with the second opinion, either?

Dr. Clancy: If you get a second opinion and you’re still not satisfied, or neither opinion is terribly clear, you may need to get a third opinion to help clarify your situation. Ultimately, you have to be comfortable and confident that you have the right diagnosis, that the right treatment has been recommended, and that you’ve got the right health care provider to work with. You have a right, and a right that you can exercise, to be involved with your own health care.

Debra: And if a patient chooses to switch providers, how does he make sure he gets his medical records from his previous doctor? Can he just ask for them or are they the property of the doctor’s office?

Dr. Clancy: This is a great question because it’s very important that the new doctor get your medical history from the previous doctor’s records. You are always entitled to see your medical records and to get copies of them. You’re probably going to need to contact the previous doctor’s receptionist or their business office and ask for copies. They may charge you a small fee for photocopying. They are going to want you to sign a form that it’s okay to do this and send it on to the next physician.

Debra: Dr. Clancy, do you have any last pieces of advice on what to do if you are just not comfortable talking to your doctor?

Dr. Clancy: It’s very important to remember that if you’re not comfortable with a doctor, it’s possible that you’re not going to follow that person’s advice no matter how good it is, and you’re going to ultimately do yourself a disservice. If you do have a problem, talk with your doctor and see if you can solve it together, but in the end, it is about your health and you’re always in charge of your health, so it’s very important to realize that you may come to a point in the road where you simply need to say this is not the best thing for me and move on.

Debra: Dr. Clancy, thank you for being here.

Dr. Clancy: Thank you.

Debra: To hear more of this interview with Dr. Clancy, please go to this program’s Web page at healthcare411.ahrq.gov.

(music)

Rand: That’s it for the week. For more information on these and other health-related stories and topics go to www.ahrq.gov. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Debra James, I’m Rand Gardner. Please join us for the next edition of Healthcare 411.